Diabetes

Overview

Diabetes is a condition in which too much sugar, or glucose, remains in the blood because the body doesn't properly convert it to energy. This happens when there's a lack of insulin — a hormone that allows sugar to enter cells to be converted into energy — or when insulin isn't working well.

During the normal digestion process, the pancreas senses the amount of sugar in the bloodstream and releases insulin to keep blood sugar in a normal range. With diabetes, the pancreas doesn't produce the right amount of insulin. Sugar accumulates in the blood and spills over into the urine, causing frequent urination, a symptom of diabetes.

Diabetes is the fifth deadliest condition in the United States, affecting children, teenagers and adults. If diabetes isn't managed properly, high blood sugar levels over many years can lead to complications, including blindness, kidney failure and loss of sensation in the extremities that could result in amputation. Maintaining near-normal blood sugar levels can delay or prevent these complications.

Types of Diabetes

There are several types of diabetes, which have different causes and symptoms. They include:

Type 1 Diabetes

Type 1 diabetes most often affects children and adults under the age of 35, but older adults also can have the disease. In type 1 diabetes, the insulin-producing beta cells in the pancreas stop making insulin. Although the cause of the condition is unknown, research has shown that type 1 diabetes results from an underlying genetic risk coupled with one or more environmental exposures. In type 1 diabetes, the immune system attacks and destroys the insulin-producing cells, which is why the condition is referred to as an autoimmune disease. Although signs and symptoms seem to develop rapidly over weeks to months, the destruction of beta cells often occurs slowly over years.

Type 2 Diabetes

This form of diabetes differs from type 1 in that the initial problem is thought to be the body's increased resistance to insulin. The body's fat, muscle and liver cells don't respond to insulin properly, making it difficult for sugar to enter the cells. Initially, the insulin-producing cells in the pancreas try to compensate by making more insulin, but may not be able to sustain this increased production over time. At that point, blood sugars start to rise and diabetes develops.

Type 2 diabetes usually occurs in people over age 45, but can affect children and teenagers, especially those with family members who have type 2 diabetes. It is the most common form of diabetes, and is becoming even more common. The condition affects an estimated one in 20 people in the United States and occurs 10 times more often than type 1. Type 2 tends to run in families and in some cases appears to be inherited as a dominant trait.

Being overweight and inactive increases the chances of developing type 2 diabetes. African Americans, Hispanic or Latino Americans, American Indians, Asian Americans and Native Hawaiians or other Pacific Islanders tend to be at a higher risk than Caucasians.

Gestational Diabetes

Gestational diabetes refers to diabetes that is diagnosed during pregnancy. It occurs in about seven percent of all pregnancies. The condition usually develops in the second half of pregnancy due to insulin resistance. If gestational diabetes is not treated, the mother and fetus may experience complications. Gestational diabetes typically resolves after delivery, but women who experience gestational diabetes are at risk of developing type 2 diabetes later in life.

Maturity Onset Diabetes of the Young (MODY)

The main characteristic of maturity onset diabetes of the young (MODY) is a diagnosis before the age of 35 in at least three generations of family members. Accounting for two to five percent of all cases of diabetes, this condition is due to a single gene that's passed down from generation to generation as a dominant trait. Several genetic defects affecting the beta cell and insulin production and secretion have been noted in relation to this condition. Some people with MODY are treated with insulin. Others can be treated with oral diabetes medications.

Signs & symptoms

Some of the common symptoms of all forms of diabetes include:

• Bedwetting in children who have been toilet trained
• Blurred vision
• Dry, itchy skin
• Extreme hunger
• Fatigue or low energy level
• Nausea
• Poorly healing wounds
• Thirst
• Tingling in the feet
• Urinating often, especially at night
• Weight loss
• Yeast infections

Diabetes often goes undiagnosed because these symptoms seem harmless or people aren't aware of them.

Diagnosis

In diagnosing diabetes, your child's doctor will conduct a thorough medical history and physical examination, making note of any symptoms that may be related to diabetes. If your child's doctor suspects diabetes, a series of tests will be recommended to make a definite diagnosis. These may include:

• Blood Sugar Test — Also known as a glucose test, this is the standard test for diagnosing type 1 and type 2 diabetes. In the test, blood is drawn to check blood sugar levels. For a fasting blood sugar test, your child must not eat or drink anything for at least eight hours prior to the test. A diagnosis of diabetes will be made if your child has a fasting blood sugar level of 126 milligrams per deciliter (mg/dl) or higher on two separate days. A normal fasting blood sugar level is between 70 to 100 mg/dl.
  
  The doctor may order a random blood sugar test. A diagnosis of diabetes will be made if your child has symptoms of diabetes and a random blood sugar level higher than 200 mg/dl, regardless of when your child last ate, on two occasions.
• Glucose Tolerance Test — This test measures the body's ability to metabolize glucose, the sugar the body uses for energy. After an overnight fast, your child will drink a solution containing a known amount of sugar. Blood is drawn before your child drinks the solution, and again every 30 to 60 minutes after, for up to three hours. Blood sugar levels above normal limits at the times measured may result in a diabetes diagnosis.

Treatment

Managing your child's diabetes is a group effort involving the whole family. At UCSF Benioff Children's Hospital, our team — including doctors, dietitians, nurses, educators and social workers — work closely with your family to provide treatment, information, support, guidance and help. Your doctor will help you and your child develop a daily diabetes treatment plan.

Diabetes management is designed to keep your child's blood sugar levels in a near-normal range and prevent erratic swings. The treatment plan will also promote your child's normal physical and emotional development.

Treatment typically involves following a healthy meal plan, getting regular exercise, checking blood sugar levels, participating in regular screenings for long-term complications of diabetes and taking insulin or oral medication as prescribed. The treatment plan is reviewed and revised as necessary. It's generally recommended that patients visit the Pediatric Diabetes Program every three months.

Meal Planning

Healthy meal planning is an essential part of your diabetes treatment. Family support in following the plan and setting up regular meal times is key to success, especially if your child or teen is taking insulin. A registered dietitian will work with you and your child to develop a healthy meal plan that:

• Maintains targeted blood sugar levels based on your child's diet, exercise and diabetes medications
• Controls your child's weight
• Provides proper nutrition to promote normal physical and emotional growth

Your doctor and dietitian also will discuss food tips for managing diabetes. These include:

• Learning which foods contain carbohydrates and how much carbs should be included at meals and snacks. Carbohydrate intake will raise your child's blood sugar levels, so the amount of carbohydrates eaten must be matched with exercise and insulin and other medications to balance blood sugar levels. For more information, please see Carbohydrates and Diabetes.
• Correctly reading food labels
• Establishing correct portion size and caloric intake based on your child's age, weight and activity levels
• Timing of meals, medications and physical activity
• Tracking dietary fat, cholesterol and sodium, as needed
• Preventing and treating hypoglycemia

Exercise

Regular physical activity is important for all children, especially those with diabetes. Exercise helps insulin work more efficiently, lowers blood sugar, burns calories and helps control weight. It also improves cholesterol levels, muscle tone and a person's sense of well-being.

If your child isn't used to regular physical activity, we recommend starting slowly and working up to 30 to 60 minutes each day. It's important that your child do something he or she likes, such as walking, dancing, swimming, sports or riding a bike. Before your child begins exercising, we suggest testing blood sugar. Ask your doctor if your child needs to test it during and after exercise as well, and if diabetes pills or insulin doses need to be reduced before beginning a regular exercise program.

Parents and family members can participate in a child's exercise program. It can be a great way for families to spend quality time together. Your diabetes educator can discuss ways to encourage exercise and participate in regular physical activity.

Blood Sugar Levels

All people with diabetes, including children and teens, need to regularly check blood sugar levels. Checking blood sugar levels tells us a number of important factors:

• The current state of your child's diabetes at a particular time
• How exercise, food and illness affects diabetes
• How well diabetes medication is working

You or your child should check blood sugar levels regularly with a blood glucose meter, preferably a meter with a built-in memory. We will teach you and your child how to use this meter. Blood glucose meter results indicate whether blood sugar levels are in the target range, too high or too low. Your child's diabetes team will recommend a target range for blood sugar and how often to test it.

We recommend that you or your child, depending on age, keep a journal or other records of blood sugar results to discuss with your doctor or nurse. You should bring your glucose meter or glucometer and written records to all clinic appointments. This information helps determine if we need to make any changes to your child's treatment plan. Keeping a written record makes it easier for you and your family to identify potential problems before your next scheduled visit. As soon as issues or problems are identified, you should discuss them with your doctor.

For more information on how to check your child's blood sugar levels and the American Diabetes Association's recommendations on age-specific blood sugar goal range, please see Tips For Checking Blood Sugar.

Medications

There are two kinds of diabetes medicines: insulin, which is taken by injection, and pills that are taken orally. For type 1 diabetes, a child or teen takes insulin shots at regular times each day. Some patients use an insulin pump to deliver insulin. Some children or teens with type 2 diabetes need pills or insulin shots or both. In all cases, medications should be balanced daily with food and activity. It's important that children or teenagers take all their diabetes medication as prescribed. Parents, caregivers, school nurses and others can help a child or teen learn how to take medications properly.

Insulin

Insulin, a hormone made by beta cells in the pancreas, lowers the blood sugar level and is injected under the skin. Until a cure is found, a person with type 1 diabetes must take insulin injections or wear an insulin pump. Injections are usually taken three or more times a day. A variety of insulin preparations are available that have different properties.

Most people use a combination of intermediate or long-acting insulin with short-acting insulin. Many children and teens receive insulin through insulin pumps that provide greater flexibility in diets and sleep schedules as well as freedom to pursue activities without worrying as much about their blood sugar levels. The insulin pump is a small device about the size of a pager or a deck of cards that can be clipped to the waistband. You, your child and your diabetes care team will decide if and when "the pump" is right for helping to manage your child's diabetes.

Oral Medications

Diabetes pills may be prescribed if you have type 2 diabetes. There are several types of oral medications:

• Sulfonylureas such as glipizide (Micronase), glyburide (Glucotrol) and glimepiride (Amaryl) — These medications help the pancreas release more insulin. Sulfonylureas usually are taken once or twice a day. They raise insulin levels for several hours. A low blood sugar is a possible side effect. People taking this medication should not skip meals. Mild weight gain, usually less than five pounds, may occur.
• Meglitinides such as nateglinide (Starlix) and repaglinide (Prandin) — These medications work in the same way as sulfonylureas, but don't last as long. They're taken right before a meal. People taking this medication should not skip meals. A low blood sugar is a possible side effect. Mild weight gain, usually less than five pounds, may occur.
• Starch Blockers such as acarbose (Precose) and miglitol (Glyset) — These medicines slow the digestion and absorption of starches and sugars. They're taken with the first bite of a meal. Gas and bloating are common side effects. When taking starch blockers, it's important that glucose tablets, not sugar candies, are used to correct a low blood sugar because starch blockers also block the absorption of sugar.
• Biguanide such as metformin (Glucophage) — This medication keeps the liver from releasing too much sugar. Metformin is usually taken twice or three times a day with a meal, although extended release forms are available that are taken only once daily. Metformin can cause diarrhea and stomach upset. To reduce diarrhea, metformin is taken with food. Diarrhea usually goes away over time.
• Thiazolidinediones (TZDs) such as pioglitazone (Actos) and rosiglitazone (Avandia) — Thiazolidinediones (TZDs) decrease insulin resistance and allow the body to use insulin better. They usually are taken once a day. TZDs can cause mild fluid retention, swelling and weight gain. A blood test to check liver function should be done every two months the first year of treatment and then every six to 12 months.